Journal of Anxiety Disorders 25 (2011) 467473

Contents lists available at ScienceDirect

Journal of Anxiety Disorders

Childhood trauma and current psychological functioning in adults with social

anxiety disorder
Janice R. Kuo a, , Philippe R. Goldin a , Kelly Werner a , Richard G. Heimberg b , James J. Gross a
a
b

Department of Psychology, Stanford University, Stanford, CA, United States

Department of Psychology, Temple University, Philadelphia, PA, United States

a r t i c l e

i n f o

Article history:
Received 30 July 2010
Received in revised form
13 November 2010
Accepted 19 November 2010
Keywords:
Social anxiety disorder
Social phobia
Anxiety
Trauma
Abuse
Neglect

a b s t r a c t
Etiological models of social anxiety disorder (SAD) suggest that early childhood trauma contributes to
the development of this disorder. However, surprisingly little is known about the link between different forms of childhood trauma and adult clinical symptoms in SAD. This study (1) compared levels of
childhood trauma in adults with generalized SAD versus healthy controls (HCs), and (2) examined the
relationship between specic types of childhood trauma and adult clinical symptoms in SAD. Participants
were 102 individuals with generalized SAD and 30 HCs who completed measures of childhood trauma,
social anxiety, trait anxiety, depression, and self-esteem. Compared to HCs, individuals with SAD reported
greater childhood emotional abuse and emotional neglect. Within the SAD group, childhood emotional
abuse and neglect, but not sexual abuse, physical abuse, or physical neglect, were associated with the
severity of social anxiety, trait anxiety, depression, and self-esteem.
2010 Elsevier Ltd. All rights reserved.

1. Introduction
Social anxiety disorder (SAD) is a common (12.1% lifetime
prevalence) (Kessler, Berglund, et al., 2005; Kessler, Chiu, Demler,
Merikangas, & Walters, 2005) and often debilitating disorder
(Lochner et al., 2003; Schneier et al., 1994) that is characterized
by persistent fear of social or performance situations in which an
individual is at risk for embarrassment, humiliation, or possible
scrutiny by unfamiliar persons (American Psychiatric Association,
2000). SAD affects more than 15 million American adults during
any 12-month period (Kessler et al., 2005).
These statistics are particularly compelling in light of evidence
suggesting that SAD is associated with signicant distress and functional impairment in both work and social domains (Lochner et al.,
2003; Rapee, 1995; Schneier et al., 1994; Sherbourne et al., 2010).
SAD may be a risk factor for other clinical disorders with which it
commonly co-occurs, including major depression, substance abuse,
and other anxiety disorders (Chou, 2009; Lampe, Slade, Issakidis, &
Andrews, 2003; Matza, Revicki, Davidson, & Stewart, 2003; Ohayon
& Schatzberg, 2010; Randall, Thomas, & Thevos, 2001). In addition,
the number of feared social situations reported by individuals with
SAD is associated with comorbid major depression, other anxiety

Corresponding author at: Ryerson University, 250 Victorica Street, Toronto,

Ontario, Canada M5B 2K3. Tel.: +1 416 979 5000x2624.
E-mail addresses: jkuo@psych.ryerson.ca, jrkuo@stanford.edu (J.R. Kuo).
0887-6185/$ see front matter 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.janxdis.2010.11.011

disorders, and suicidal ideation (Gabalawy, Cox, Clara, & Mackenzie,

2010).
Contemporary models of SAD suggest that the development of
SAD is a result of a biological vulnerability coupled with negative social learning experiences (Clark & Wells, 1995; Heimberg,
Brozovich, & Rapee, 2010; Rapee & Heimberg, 1997). Findings from
family studies demonstrate a strong association between social
anxiety in parent and offspring (Bgels et al., 2001; Lieb et al.,
2000), and temperament studies suggest a link between inhibited
temperament in childhood and the development of social anxiety in adolescence (Biederman et al., 2001; Schwartz, Snidman,
& Kagan, 1999). The impact of social learning experiences has
been suggested as a key environmental factor contributing to the
development of the disorder (Rapee & Heimberg, 1997) and has
received substantial empirical attention. Prospective studies have
found that parental overprotection, rejection, and lack of warmth
are associated with offspring SAD (Lieb et al., 2000; Knappe, Beesdo,
Fehm, Hoer, et al., 1999; Knappe, Beesdo, Fehm, Lieb, & Wittchen,
2009).
One specic social learning factor that has garnered recent
attention is childhood trauma. Although extant data indicate that
childhood trauma experiences may contribute to the development
of SAD (Arrindell, Emmelkamp, Monsma, & Brilman, 1983; Arrindell
et al., 1989; Bruch & Heimberg, 1994), how childhood trauma
impacts adult clinical functioning in SAD remains unknown. The
purpose of the current study was to address this gap by comparing
histories of childhood trauma between individuals with SAD and

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J.R. Kuo et al. / Journal of Anxiety Disorders 25 (2011) 467473

non-clinical controls and examining associations between specic

types of childhood trauma and adult clinical symptoms in SAD.
1.1. The role of early childhood trauma in the development of SAD
Studies investigating childhood trauma in SAD suggest that
parental emotional abuse towards the child (e.g., swearing, insulting, denigrating, and non-physical aggressing) and emotional
neglect (e.g., emotional deprivation or the absence of feeling special, loved, or being part of a nurturing environment) may be
important factors in the development of SAD. For example, in a
non-clinical sample, compared to women with low levels of social
anxiety, women high in social anxiety reported signicantly more
paternal rejection, paternal and maternal neglect, and paternal
authority-discipline (Klonsky, Dutton, & Liebel, 1990). In another
study, Lieb et al. (2000) found that parental rejection was associated
with social anxiety in a community sample of adolescents.
Studies of adults with SAD also indicate that these individuals report childhood experiences associated with emotional abuse
and/or neglect. Individuals with SAD are more likely than controls
to perceive their parents as having used shame as a form of discipline (Bruch & Heimberg, 1994). Two separate studies (Arrindell
et al., 1983, 1989) found that, compared to non-anxious healthy
controls, patients with SAD characterized their parents as rejecting and lacking in emotional warmth, although these ndings
should be interpreted with caution because of small sample sizes.
Simon et al. (2009) recently reported that 56% of individuals with
SAD endorsed a history of childhood emotional abuse, and 39% of
individuals with SAD endorsed a history of childhood emotional
neglect. However, this study did not include a healthy control
group, so it remains unclear whether these rates differ from those
in non-clinical samples.
In addition to emotional abuse and neglect, studies have investigated both (a) rates of SAD in adults with a history of childhood
sexual abuse and (b) rates of childhood sexual abuse in adults
with SAD. Using the former method, Pribor and Dinwiddie (1992)
reported higher rates of SAD in adults with a history of sexual abuse
than an age- and race-matched control group (SAD: 46.2% versus
healthy controls: 2.8%). Employing the latter method, adults with
SAD endorsed higher rates of childhood sexual abuse (SAD: 10.0%
versus healthy controls: 5.0%) (Bandelow et al., 2004). However,
when familial anxiety was controlled, childhood sexual abuse only
predicted a diagnosis of SAD at a trend level. These ndings suggest that childhood sexual abuse may not play a unique role in the
development of SAD.
1.2. The psychological correlates of early childhood trauma
Given that individuals with SAD appear to differ from healthy
controls in their exposure to early childhood trauma, one important
question is whether these early adverse experiences are correlated
with one or more aspects of negative psychological functioning
in SAD. In non-clinical samples, studies demonstrate associations
between a history of childhood trauma and a number of negative
adult experiences including elevated levels of depression, anxiety, substance use, suicidal behaviors, and emotional-behavioral
problems (Briere & Elliott, 1994; Briere & Runtz, 1988; Silverman,
Reinherz, & Giaconia, 1996).
More recent studies have evaluated whether distinct forms of
childhood trauma are related to specic psychological problems
in adulthood. In a sample of young women, physical abuse was
related to heightened aggression towards others and sexual abuse
was related to maladaptive sexual behavior (e.g., getting into trouble because of sexual behavior, controlling others through the
use of sex) (Briere & Runtz, 1990). By contrast, emotional abuse
was related to low self-esteem. In a separate study, women who

reported a history of emotional neglect reported greater problems

in multiple domains (adult attachment styles, anxiety, depression,
somatization, paranoia) than those reporting a history of physical abuse (Gauthier, Stollak, Messe, & Aronoff, 1996). Briere and
Runtz (1988) found that maternal physical abuse was associated
with interpersonal sensitivity and dissociation, whereas paternal
emotional abuse was associated with anxiety, depression, interpersonal sensitivity, and dissociation. Gibb and colleagues found
that childhood emotional abuse was more strongly related to
diagnoses of depression or social anxiety disorder than either
physical or sexual abuse (e.g., Gibb, Chelminiski, & Zimmerman,
2007).
Despite mounting evidence for the associations between different forms of abuse and various adverse adult clinical symptoms,
very few studies have extended this line of inquiry to SAD. Simon
et al. (2009) recently examined the relationship between various types of childhood trauma and the severity of social anxiety,
global severity of symptoms, disability, resilience, and quality of
life in a sample of adults with SAD. A history of childhood emotional abuse or neglect was associated with greater severity of
SAD and global symptoms; emotional neglect was also associated with lesser resilience. Childhood sexual abuse was associated
with greater disability, whereas childhood physical abuse and
neglect were not associated with any of these psychological outcomes.
These ndings indicate some specicity in the relationship
between childhood trauma subtypes and general functional
impairment in SAD. However, whether subtypes of childhood
trauma might be differentially associated with specic clinical
symptoms that have been implicated in the non-clinical literature
(e.g., depression, anxiety, self-esteem) remains unknown. Given the
evidence that SAD individuals with a history of childhood trauma
have poorer treatment outcomes (Alden, Taylor, Laposa, & Mellings,
2006), such knowledge would be useful in developing treatment
interventions for this group who does not maximally benet from
current treatments.
1.3. The present study
The present study was designed to address two goals. The rst
goal was to compare differences in the frequency (how often an
event occurred) and rates (what percent of the time an event
occurred) of different forms of childhood trauma (sexual abuse,
physical abuse, physical neglect, emotional abuse, and emotional
neglect) in a large sample of individuals with generalized SAD
versus a comparison group of healthy control participants (HCs).
This addresses limitations in the current literature which include
small clinical samples (Arrindell et al., 1983, 1989) and the lack of
an HC group (Simon et al., 2009). The second goal was to build
upon recent ndings linking subtypes of childhood trauma and
functional impairment in individuals with SAD (Simon et al., 2009)
by examining associations between different forms of childhood
trauma and specic adult clinical symptoms (anxiety, depression,
and self-esteem) in SAD.
We hypothesized that, compared to HCs, individuals with SAD
would have greater frequency and rates of childhood emotional
abuse, emotional neglect, sexual abuse, physical abuse, and physical neglect. In line with previous ndings (Simon et al., 2009),
we expected that a greater frequency of childhood emotional
abuse and neglect in the SAD sample would be associated with
greater severity of current social anxiety. Drawing upon ndings
in non-clinical samples, we also predicted that greater frequency
of childhood emotional abuse and neglect, but not sexual abuse,
physical abuse, or physical neglect would be associated with
greater anxiety, depression, and lower self-esteem within the SAD
group.

J.R. Kuo et al. / Journal of Anxiety Disorders 25 (2011) 467473

2. Methods
2.1. Participants
Participants were part of two larger brain imaging studies evaluating the mechanisms underlying cognitive behavioral
and mindfulness-based treatments for SAD. Participants included
102 (53 females) individuals who met DSM-IV-TR (American
Psychiatric Association, 2000) criteria for a primary diagnosis of
generalized SAD and 30 healthy controls (15 females) with no lifetime history of any DSM-IV psychiatric disorders that are assessed
as part of the Anxiety Disorders Interview Schedule for DSM-IV, lifetime version (ADIS-IV-L; DiNardo, Brown, & Barlow, 1994). Because
they were originally selected to participate in the brain imaging
study, potential participants were excluded based on the criteria
for that study: current use of any psychotropic medication or any
history of neurological or cardiovascular disorders. SAD individuals
were also excluded if they met criteria for any current DSM-IV Axis
I psychiatric disorder assessed by the ADIS-IV-L other than generalized anxiety disorder (n = 24, 23.5%), agoraphobia (n = 1, 1.0%),
or specic phobia (n = 10, 9.8%). All participants provided informed
consent in accordance with Stanford Universitys Human Subjects
Committee guidelines.
2.2. Measures
Eligible participants were administered the short form of the
Childhood Trauma Questionnaire (CTQ-SF; Bernstein et al., 2003),
a 28-item questionnaire (25 clinical items and three validity items)
which assesses ve specic forms of childhood trauma: sexual
abuse (e.g., Someone tried to touch me in a sexual way, or tried
to make me touch them), physical abuse (e.g., I was punished
with a belt, a board, a cord, or some other hard object), physical
neglect (e.g., I had to wear dirty clothes), emotional abuse (e.g.,
People in my family called me things like stupid, lazy, or ugly),
and emotional neglect (I felt loved reverse coded). Respondents
are asked to choose responses on a 5-point Likert-type scale that
ranges from never true to very often true. The subscales of the CTQ
have moderate to high internal consistency (alphas = .61.92) in a
community sample (Bernstein et al., 2003). In the current sample,
the CTQ had moderate to high internal consistency (alpha = .49 for
HC, alpha = .86 for SAD), as did the subscales (alpha = .27.90 for HC,
alpha = .43.92 for SAD).
Participants also completed questionnaires assessing clinical
symptoms in several domains. Severity of social anxiety was measured using the Social Interaction Anxiety Scale (SIAS; Mattick
& Clarke, 1998), a 20-item self-report measure assessing anxiety
related to social interactions in dyads and groups. The SIAS has
demonstrated high levels of internal consistency (alphas = .88.90
for undergraduate and community samples, alpha = .93 for SAD
individuals) and testretest reliability (r = .91 for undergraduate
sample, r = .92 for SAD individuals) (Carter & Wu, 2010; Mattick
& Clarke, 1998). Anxiety was measured using the Trait portion of
the State-Trait Anxiety Inventory (STAI-T; Speilberger, Gorsuch, &
Lushene, 1970), a well-established measure of trait anxiety with
high testretest reliability (ranging from r = .73 to .86) (Speilberger
et al., 1970). Internal consistency for the STAI-T in this sample was
high (alpha = .81 in HC, alpha = .93 in SAD). Depressive symptoms
were measured using the Beck Depression Inventory-II (BDI-II;
Beck, Steer, & Brown, 1996), a 21-item self-report measure of
depressive symptoms measured during the past week. The BDI
has good internal consistency (alpha = .90 in a college sample;
Storch, Roberti, & Roth, 2004); (alpha = .89 in a sample of individuals with SAD; Coles, Gibb, & Heimberg, 2001) and concurrent
validity (r = .69 with the State-Anxiety Inventory depression factor),
and good testretest reliability (ICC = .91) in a sample of individu-

469

als with SAD (Coles et al., 2001). Self-esteem was measured using
the Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1989), a 10item self-report measure assessing beliefs and attitudes regarding
general self-worth. The RSES has been shown to have satisfactory
convergent validity (rs = .56.83) and good testretest reliability
(r = .85; Silbert & Tippett, 1965). Internal consistency in this sample
was high (alpha = .81 in HC, alpha = .89 in SAD).
2.3. Procedures
As part of the larger treatment trials, participants were recruited
through web-based community listings and referrals from local
mental health clinics. Following a telephone screening to determine initial eligibility, potential participants were administered the
ADIS-IV-L to determine diagnostic status. Participants lled out the
assessment measures (see Section 2.2) as part of a ve-h baseline
clinical battery.
2.4. Data analysis
Examination of assumptions of multivariate analysis of variance indicated violations of homogeneity and normality for total
CTQ scores as well as CTQ trauma subtype (sexual abuse, physical abuse, physical neglect, emotional abuse, emotional neglect)
scores. Therefore, a non-parametric MannWhitney test was used
to examine between-group differences in the endorsed frequency
of total childhood trauma and each trauma subtype. To examine between-group differences in the rates of childhood trauma,
we applied previously validated cut-offs for each CTQ subscale
to determine the presence of each type of childhood trauma
(Walker et al., 1999): sexual abuse 8, physical abuse 8, physical neglect 8, emotional abuse 10, emotional neglect 15. The
MannWhitney test was then used to examine between-group differences in the rates of childhood trauma and each trauma subtype.
To examine relations between the frequency of each childhood
trauma subtype and current clinical symptoms (social anxiety,
trait anxiety, depression, and self-esteem) within the SAD group,
Spearmans rho was used. Given previous reports of signicant
associations between childhood emotional neglect and depression
(e.g., Gibb et al., 2007), we also examined the associations between
childhood emotional abuse and neglect with social anxiety, trait
anxiety, and self-esteem while controlling for current levels of
depression using partial correlations. Bonferroni adjustments were
not employed as the purpose of these analyses was not to examine
the universal null hypothesis (Perneger, 1998).
3. Results
3.1. Preliminary analyses
Preliminary analyses were conducted to assess (1) whether
there were demographic differences between SAD and HC groups,
(2) the associations among childhood trauma variables, (3) the
associations among demographic variables and childhood trauma
variables, (4) the associations among clinical symptom variables,
and (5) between-group differences in the clinical symptom variables.
3.1.1. Demographic variables
There was no signicant between-group difference in age (SAD:
M = 33.47, SD = 8.59, HC: M = 32.60, SD = 9.00, t(130) = 0.48, p = .63)
or in number of years of education (SAD: M = 16.69, SD = 2.22, HC:
M = 17.48, SD = 2.03, t(122) = 1.72, p = .09), although education data
were missing for eight participants (7 SAD, 1 HC). Gender did not
differ signicantly across the groups, 2 (1, n = 132) = 0.04, p = .85.

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J.R. Kuo et al. / Journal of Anxiety Disorders 25 (2011) 467473

Table 1
Correlations among age, gender, and Childhood Trauma Questionnaire subscales in individuals with social anxiety disorder (n = 102) (below diagonal) and healthy controls
(n = 30) (above diagonal).

Age
Sexual abuse
Physical abuse
Physical neglect
Emotional abuse
Emotional neglect

Age

Sexual abuse

Physical abuse

Physical neglect

Emotional abuse

Emotional neglect

.19
.13
.05
.26**
.35***

.42*

.32**
.33**
.17
.15

.19
.13

.26**
.43**
.42**

.08
.03
.12

.32**
.21*

.18
.13
.29
.18

.77**

.23
.09
.09
.11
.56**

Note. Correlations represent Spearmans rho.

*
p < .05.
**
p < .01.
***
p < .001.

3.1.2. Relationships among types of childhood trauma

Within the SAD group, all ve childhood trauma subscales (sexual abuse, physical abuse, physical neglect, emotional abuse, and
emotional neglect) were signicantly positively associated with
each other, with the exception of the correlations between sexual
abuse and either emotional abuse or neglect. Only emotional abuse
and emotional neglect were signicantly positively associated in
the HC group (see Table 1).
3.1.3. Relations among demographic variables and types of
childhood trauma
Age was signicantly positively associated with childhood
sexual abuse in the HC group and was signicantly positively
associated with childhood emotional abuse and emotional neglect
in the SAD group (see Table 1). MannWhitney tests indicated
that males had greater histories of childhood physical abuse than
females in the SAD group only (U = 913.00, p < .01). All other comparisons were non-signicant (SAD: sexual abuse, U = 1237.50,
p = .59; physical neglect, U = 1153.50, p = .90; emotional abuse,
U = 1158.50, p = .35; emotional neglect, U = 1090.00, p = .56; HC: sexual abuse, U = 105.50, p = .78; physical abuse, U = 106.00, p = .81;
physical neglect, U = 92.50, p = .51; emotional abuse, U = 96.50,
p = .51; emotional neglect, U = 92.50, p = .41).
3.1.4. Relations among clinical variables
Associations between clinical variables (social anxiety, trait anxiety, depression, and self-esteem) were moderate for both groups
(see Table 2).
3.1.5. Differences in social anxiety, trait anxiety, depression, and
self-esteem between patients with SAD and HCs
Independent-sample t-tests demonstrated signicant betweengroup differences in social anxiety, trait anxiety, depression, and
self-esteem (see Table 3).
3.2. Differences in childhood trauma between patients with SAD
and HCs
MannWhitney tests demonstrated that, compared to HCs, individuals with SAD reported greater frequency of emotional abuse
Table 2
Correlations among clinical symptom variables in individuals with social anxiety
disorder (n = 102) (below diagonal) and healthy controls (n = 30) (above diagonal).
Social anxiety
Social anxiety
Trait anxiety
Depression
Self-esteem

.38**
.25*
.40**

Trait anxiety
*

.41

.58*
.64**

Note. Correlations represent Spearmans rho.

*
p < .05.
**
p < .01.

Depression

Self-esteem

.03
.43*

.48**

.24
.46*
.12

Table 3
Differences in clinical symptom variables between individuals with social anxiety
disorder (n = 102) and healthy controls (n = 30).

Social anxiety
Trait anxiety
Depression
Self-esteem
***

SAD
M(SD)

HC
M(SD)

t(df)

53.18 (9.95)
54.26 (9.57)
11.91 (9.18)
25.51 (5.29)

11.37 (7.79)
28.13 (4.89)
2.11 (3.34)
35.44 (3.25)

21.28 (126)***
19.85 (126)***
8.74 (124)***
12.00 (120)***

p < .001.

Fig. 1. Differences in the endorsed frequencies of childhood trauma among individuals with social anxiety disorder (SAD) and healthy controls (HC). Error bars
represent the standard error of measurement. ***p < .001.

(U = 816.00, p < .001), emotional neglect (U = 708.00, p < .001), and

total childhood trauma (U = 835.00, p < .001) (see Fig. 1). There
was a trend towards greater childhood sexual abuse in the SAD
group (U = 1289.00, p = .07). There were no signicant betweengroup differences in childhood physical abuse (U = 1276.00, p = .14)
or neglect (U = 1258.50, p = .25).
See Table 4 for rates of each trauma subtype for both
groups. Consistent with the above analyses examining differences in endorsed per-person frequencies of childhood trauma,
MannWhitney tests demonstrated that, compared with HCs, indiTable 4
Rates of each childhood trauma subtype in individuals with social anxiety disorder
(n = 102) and healthy controls (n = 30).

Sexual abuse
Physical abuse
Physical neglect
Emotional abuse
Emotional neglect

SAD
n

18
31
93
52
37

17.6
30.4
91.2
51.0
36.3

HC
n
2
5
29
4
2

%
6.7
16.7
98.7
13.3
6.7

J.R. Kuo et al. / Journal of Anxiety Disorders 25 (2011) 467473

Table 5
Correlations between Childhood Trauma Questionnaire subscales and clinical symptoms in individuals with social anxiety disorder (n = 102).

Sexual abuse
Physical abuse
Physical neglect
Emotional abuse
Emotional neglect
*
**
***

Social anxiety

Trait anxiety

Depression

Self-esteem

.10
.12
.07
.26*
.25*

.10
.15
.04
.30**
.40***

.07
.11
.13
.18
.31**

.06
.13
.06
.35***
.44***

p < .05.
p < .01.
p < .001.

viduals with SAD had greater rates of childhood emotional abuse

(U = 954.00, p < .001) and childhood emotional neglect (U = 1077.00,
p < .01). There were no signicant between-group differences in
rates of childhood sexual abuse (U = 1362.00, p = .14), childhood
physical abuse (U = 1320.00, p = .14), or childhood physical neglect
(U = 1446.00, p < .32).
3.3. Relationships between types of childhood trauma and adult
clinical symptoms in SAD
As shown in Table 5, within the SAD sample, child emotional abuse and neglect were positively correlated with current
social anxiety and trait anxiety, and negatively correlated with
self-esteem. Childhood emotional neglect was also signicantly
positively correlated with depression. Childhood sexual abuse,
physical abuse, and physical neglect were not correlated with any of
these variables. Because of signicant associations between age and
childhood emotional abuse/neglect found in our preliminary analyses, we examined whether these signicant relations remained
when controlling for age. Results did not change (emotional
abusesocial anxiety, r = .26, p < .05, emotional abusetrait anxiety,
r = .28, p < .01, emotional abuseself-esteem, r = .35, p < .001, emotional neglectsocial anxiety, r = .25, p < .05, emotional neglecttrait
anxiety, r = .40, p < .001, emotional neglectdepression, r = .31,
p < .01, emotional neglectself-esteem, r = .44, p < .001). We further evaluated whether the observed pattern of results might be
an artifact of depressive affect by conducting partial correlations
between childhood abuse and neglect with social anxiety, trait anxiety, and self-esteem, controlling for levels of depression. Results
did not change (emotional abusesocial anxiety, r = .23, p < .05,
emotional abusetrait anxiety, r = .24, p < .05, emotional abuseselfesteem, r = .31, p < .01, emotional neglecttrait anxiety, r = .28,
p < .01, emotional neglectself-esteem, r = .35, p < .01), with the
exception of the relation between childhood emotional neglect and
social anxiety, which was no longer signicant (r = .19, p > .10).
4. Discussion
Findings from this study indicate that, compared to HCs, individuals with SAD report more frequent childhood trauma, specically,
emotional abuse and emotional neglect. Furthermore, childhood
emotional abuse and neglect were associated with current social
anxiety, trait anxiety, depression (neglect only), and self-esteem in
individuals with SAD.
4.1. Differences in childhood trauma between SAD and HC
The nding that adults with SAD endorsed histories of more
frequent childhood emotional abuse and neglect is consistent with
prior reports of greater rejection, lesser emotional warmth, and
increased use of shame among parents of adults with SAD (Arrindell
et al., 1983, 1989; Bruch & Heimberg, 1994). In contrast to previous reports (Bandelow et al., 2004), we did not observe higher

471

frequency or rates of sexual abuse (although there was a trend

towards differences in frequency) in adults with SAD.
One reason for this discrepancy may be differences in the study
samples. We examined adults with generalized SAD. Bandelow
et al. (2004) did not specify whether their participants met criteria for generalized SAD or non-generalized SAD. Differences in SAD
subtypes could potentially account for these conicting ndings.
Additionally, the current study excluded participants on medications or who met criteria for a variety of comorbid diagnoses
whereas previous studies did not. It is possible that SAD participants in our study were higher functioning (as might be indicated
by the education levels reported) than those who participated in
prior studies. Further, one notable nding was that all but one (98%)
of the HCs in the current study met threshold for physical neglect.
This is substantially higher than recently reported rate of 59% by
the U.S. Department of Health and Human Services Administration
on Children (2009). It is possible, therefore, that our null ndings
related to sexual and physical abuse are accounted for by a higher
functioning SAD and lower functioning HC sample (however, it
should be noted that individuals with SAD in our study have very
high rates of physical neglect as well; see below).
Another difference is in assessment methods. We used the CTQ,
whereas Bandelow et al. (2004) used semi-structured interviews.
The two assessment modalities may inuence what types of childhood trauma are reported by patients with SAD. Roy and Perry
(2004) reviewed several childhood trauma interview-based and
self-report instruments and noted that many of the interviews
assess responses to specic childhood trauma vignettes which
the interviewer subsequently codes as having occurred or not
occurred. In contrast, such specicity is less likely captured in selfreport instruments which tend to rely on more global questions.
It is not clear whether patients with SAD will reveal more adverse
childhood information in a self-report versus an interview format.
It is also important to note that the rates of childhood trauma
among individuals with SAD in the current study are similar to
those reported by Simon et al. (2009), with the exception of physical
neglect, for which our rates were substantially higher (91% versus
35%). This is a surprising nding, particularly given the selective
screening criteria used in this study which likely recruited for a
higher-functioning clinical group. However, taken in conjunction
with the elevated rates of physical neglect also found in the HC
group, these ndings may reect regional differences in childhood
abuse across the U.S.
4.2. Childhood trauma and current adult psychological
functioning in SAD
Childhood emotional abuse and neglect were signicantly associated with social anxiety, trait anxiety, depression (neglect only),
and self-esteem. There were no signicant associations between
childhood sexual abuse, physical abuse, or physical neglect with
these clinical symptoms among individuals with SAD. These ndings replicate Simon et al. (2009) reports that childhood emotional
abuse and neglect are associated with severity of social anxiety
among adults with SAD. They also extend prior studies as we found
these two trauma types were also related to other adult clinical
dysfunctions, specically higher trait anxiety, greater depression,
and lower self-esteem.
These results are generally congruent with what has been
reported in the non-clinical literature, that childhood emotional
abuse and neglect are associated with internally-focused symptoms, whereas childhood sexual and physical abuse are associated
with externally-focused symptoms (Briere & Runtz, 1988, 1990).
Although there is an emerging literature identifying a noveltyseeking, behaviorally disinhibited subtype of SAD (Kashdan &
Hofmann, 2008; Kashdan, McKnight, Richey, & Hofmann, 2009),

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J.R. Kuo et al. / Journal of Anxiety Disorders 25 (2011) 467473

whether childhood sexual and physical abuse are associated with

more externally destructive behaviors in SAD is a question that
warrants empirical examination.
It bears emphasizing that childhood emotional abuse and emotional neglect were highly correlated in this sample, as has been
reported elsewhere (Bernstein et al., 2003). This calls into question
the differentiation of these two constructs and necessarily limits ner delineation of the differential associations between these
two trauma subtypes and adult clinical symptoms. Rather, a more
appropriate interpretation is that a history of emotional trauma is
associated with negative adult clinical symptoms among individuals with SAD, whereas this relationship does not appear to exist
with sexual or physical trauma.
4.3. Limitations and future directions
This was a cross-sectional study, and causal inferences cannot be made. Future studies employing a longitudinal prospective
design will be needed to determine whether childhood emotional
abuse and neglect are causal factors in the subsequent development of SAD and other psychological outcomes. The current
research relied on retrospective self-report, which is limited by
social desirability effects and recall bias and which may constrain the validity of the ndings. Indeed, incorporating other
methods of assessment, such as structured interviewing of the participants, as well as their childhood caregivers, would be highly
desirable.
The current study used the CTQ to assess childhood trauma
and, therefore, was not designed to explore differential relations between paternal versus maternal abuse and adult clinical
symptoms. Given that previous studies have shown differences
in outcomes of paternal versus maternal abuse (Briere & Runtz,
1988), future studies should examine how the perpetrating parents gender may moderate clinical and functional outcomes in
SAD.
Given the evidence linking childhood trauma to various forms
of psychopathology such as depression, substance abuse, and PTSD
(Gibb et al., 2007; Burnette et al., 2008; Bremner, Southwick,
Johnson, Yehuda, & Charney, 1993), it is also unclear whether the
results from this study are specic to SAD. Although we were able
to somewhat address this issue by controlling for depression in our
main analyses, future studies should further delineate the specicity of the relation between different forms of childhood trauma
and SAD.
Future studies examining potential patient moderators such as
comorbidity, subtypes of SAD, and other individual differences (i.e.,
coping skills, personality) are also necessary, as this approach might
help clarify for whom childhood trauma will negatively impact
adult psychological functioning. Studies identifying psychological
mechanisms that may mediate the relationship between childhood
emotional abuse/neglect and adult psychological functioning could
provide greater understanding of the crucial pathways that explain
this relationship.
Acknowledgments
This research was supported by an NIMH Grant (R01 MH58147)
awarded to James Gross, as well as an NIMH Postdoctoral Fellowship and a Mind and Life Summer Research Institute grant awarded
to Philippe Goldin.
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